Provider Demographics
NPI:1710015318
Name:DAVID ALAN TIMM
Entity Type:Organization
Organization Name:DAVID ALAN TIMM
Other - Org Name:PEDIATRIC & ADOLESCENT CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:TIMM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-442-7676
Mailing Address - Street 1:1806 CARTER ST
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:LA
Mailing Address - Zip Code:71373-3115
Mailing Address - Country:US
Mailing Address - Phone:318-336-7172
Mailing Address - Fax:318-336-7176
Practice Address - Street 1:1806 CARTER ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373-3115
Practice Address - Country:US
Practice Address - Phone:318-336-7172
Practice Address - Fax:318-336-7176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA016299208000000X
LAMD016299208000000X
LAAPO4933363LF0000X
LAAPO4870363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1021829Medicaid